What should be included in a comprehensive psych intake guide?

Comprehensive Psychiatric Intake Guide

A comprehensive psychiatric intake assessment should include standardized sections for identifying information, chief complaint, history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, physical examination findings, risk assessment, impression, and treatment plan as recommended by the American Psychiatric Association. 1

Identifying Information

• Document patient demographics (name, age, gender, date of birth) 1
• Record date and time of evaluation 1
• Note source of information (patient, family, medical records, etc.) 1

Chief Complaint/Reason for Evaluation

• Document the patient's own words regarding the presenting problem 1
• Assess circumstances leading to evaluation or hospitalization 1

History of Present Illness

• Conduct a psychiatric review of systems 2
• Evaluate anxiety symptoms and panic attacks 2, 1
• Assess sleep patterns and abnormalities, including sleep apnea 2, 1
• Document assessment of impulsivity 2, 1
• Record chronology of symptom development 1

Psychiatric History

• Identify past and current psychiatric diagnoses 2, 1
• Document history of psychiatric hospitalization and emergency department visits 2
• Record past psychiatric treatments (type, duration, and doses) 2
• Assess response to past psychiatric treatments 2
• Evaluate adherence to past and current pharmacological and non-pharmacological treatments 2
• Document prior psychotic or aggressive ideas 2, 1
• Assess prior aggressive behaviors (homicide, domestic violence, threats) 2, 1
• Record prior suicidal ideas, plans, and attempts (including context, method, damage, lethality, intent) 2, 1
• Document prior intentional self-injury without suicidal intent 2

Substance Use History

• Assess use of tobacco, alcohol, and other substances 1
• Evaluate misuse of prescribed or over-the-counter medications 1
• Identify current or recent substance use disorders 1

Medical History

• Document allergies and drug sensitivities 1
• List current medications (prescribed, non-prescribed, supplements) 1
• Assess primary care relationship 1
• Record past/current medical illnesses and hospitalizations 1
• Evaluate cardiopulmonary status 1
• Assess endocrinological disease 1
• Screen for infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 1

Family History

• Assess psychiatric disorders in biological relatives 1
• Document history of suicidal behaviors in relatives (especially for patients with suicidal ideation) 1

Personal and Social History

• Identify psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Assess trauma history 1

Physical Examination

• Measure height, weight, and BMI 1
• Record vital signs 1
• Assess general appearance and nutritional status 2
• Evaluate coordination and gait 2
• Document involuntary movements or abnormalities of motor tone 2
• Assess sight and hearing 2

Mental Status Examination

• Evaluate appearance and behavior 1
• Assess speech (fluency and articulation) 2, 1
• Document mood and affect 2, 1
• Evaluate thought process (logical, tangential, circumstantial, etc.) 1
• Assess thought content and perception 2
• Document level of anxiety 2
• Evaluate cognition 2

Risk Assessment

• Assess current suicidal ideas, plans, and attempts 2, 1
• If suicidal ideas are present, evaluate:
  • Patient's intended course of action if current symptoms worsen 2
  • Access to suicide methods including firearms 2
  • Patient's possible motivations for suicide 2
  • Reasons for living 2
  • Quality and strength of the therapeutic alliance 2
• Document hopelessness 2
• Assess current aggressive or psychotic ideas 2, 1
• Provide a documented estimate of suicide risk with influencing factors 2, 1
• Document an estimated risk of aggressive behavior (including homicide) 2

Impression and Plan

• Develop a diagnostic formulation based on the comprehensive assessment 1
• Document the rationale for treatment selection, including specific factors that influenced the treatment choice 2, 1
• Consider the patient's treatment preferences 2, 1
• Explain to the patient: differential diagnosis, risks of untreated illness, treatment options, benefits and risks of treatment 2
• Collaborate with the patient about treatment decisions 2
• Determine appropriate disposition plan (level of care) 1

Special Considerations for Children and Adolescents

• For pediatric patients, obtain a medical history and consider medical evaluation before initiating pharmacotherapy 2
• Consider targeted medical testing to establish a baseline before starting medications with known risks 2
• For adolescents, balance confidentiality needs with the need for parents to have information for treatment decisions 2

Documentation Requirements

• Clearly document all sections with date and time 1
• Provide authentication by the evaluating clinician 1
• Consider including quantitative measures of symptoms, level of functioning, and quality of life 2
• Document the rationale for clinical tests 2